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Chest Wall Resection and Reconstruction for Non-Small-Cell Lung Cancer

  • Benjamin D. Kozower
    Correspondence
    Address reprint requests to Benjamin D. Kozower, MD, Assistant Professor of Surgery, General Thoracic Surgery, University of Virginia Health System, Box 800679, Charlottesville, VA 22908-0679.
    Affiliations
    General Thoracic Surgery, University of Virginia Health System, Charlottesville, Virginia.
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      Chest wall involvement occurs in less than 8% of patients with newly diagnosed non-small-cell lung cancer. In the absence of metastatic spread, en-bloc anatomic surgical resection of the involved lung and chest wall is the primary treatment for most patients. These lesions are T3 tumors and, because of the favorable survival following surgical resection of T3N0 tumors, they have been reclassified as stage IIB disease.
      • Burkhart H.M.
      • Allen M.S.
      • Nichols 3rd, F.C.
      • et al.
      Results of en bloc resection for bronchogenic carcinoma with chest wall invasion.
      If lymph node involvement is present, the overall survival following resection of T3 tumors is reduced such that T3 N1 to 2 tumors remain in the stage IIIA category. Factors that influence survival in this group of patients include completeness of resection, the extent of chest wall invasion, and the presence of regional lymph node metastasis.
      • Matsuoka H.
      • Nishio W.
      • Okada M.
      • et al.
      Resection of chest wall invasion in patients with non-small cell lung cancer.
      • Doddoli C.
      • D’Journo B.
      • Le Pimpec-Barthes F.
      • et al.
      Lung cancer invading the chest wall: a plea for en-bloc resection but the need for new treatment strategies.
      Controversy exists regarding the significance of the depth of penetration and whether or not en-bloc resection of chest wall (versus parietal pleura only) is required for adequate resection.
      • Karmy-Jones R.
      • Vallieres E.
      Non-small cell lung cancer with chest wall involvement.
      There are no randomized data to answer this question and surgeons use their personal experience and large published series to guide their practice. Because the chest wall resection typically adds minimal morbidity, my approach has been to do a chest wall resection if there is any question of achieving a complete resection.
      The need for chest wall reconstruction depends on the size and location of the defect. The main reasons to reconstruct the chest wall are to protect vital underlying structures and to prevent paradoxical chest wall motion and respiratory compromise. For defects greater than three ribs or 5 cm, some type of chest wall reconstruction is usually warranted. For anterior defects with chest wall instability, a combination of Marlex (Marlex Pharmaceuticals, New Castle, DE) and methyl methacrylate works well.
      • McCormack P.M.
      Use of prosthetic materials in chest-wall reconstruction Assets and liabilities.
      For posterior defects, a taut Marlex mesh or a Gore-Tex patch (W.L. Gore & Associates, Inc, Elkton, MD) closure is adequate. Very small defects of one to two ribs, or defects located posteriorly beneath the scapula, usually do not require reconstruction. However, if a posterior chest wall resection extends to the fifth rib or lower, chest wall reconstruction should be performed to prevent the scapula from caving into the chest.

      Operative Technique

      Figure thumbnail gr1
      Figure 1Most T3 non-small-cell lung cancers, involving the chest wall, are approached through a traditional posterolateral thoracotomy. An epidural catheter should be placed preoperatively. The patient is positioned in the left lateral decubitus position with the table flexed. It is crucial to avoid any break in sterile technique to prevent infection of the chest wall prosthesis. The incision is made midway between the spine and posterior border of the scapula, extending one finger-breath below the inferior tip of the scapula. The latissimus dorsi muscle is divided from the auscultatory triangle to the anterior aspect of the incision; the underlying serratus is elevated but not divided. m. = muscle.
      Figure thumbnail gr2
      Figure 2After the scapula is elevated with a large Finochietto retractor (Premier Medical, Kent, WA), the avascular plane can be developed between the scapula and the chest wall. If superior extension is required above the fourth rib, the trapezius muscle and the rhomboids can also be divided. The computed tomographic scan is important for preoperative planning to help choose which interspace to enter. The fifth interspace is the most common to provide access to the hilum for the combined pulmonary and chest wall resections. However, if the tumor is adherent to the fifth or sixth ribs, one can enter the chest more inferiorly. The surgeon’s hand is then placed inside the thoracic cavity to help palpate the boundaries of the chest wall involvement.
      Figure thumbnail gr3
      Figure 3One can palpate the extent of the tumor adherent to the chest wall. Much of this can be done under direct vision. It is helpful to mark the boundary of the chest wall resection with cautery. This should be at least 2 cm from the tumor to insure negative margins. Oftentimes the superior extent is difficult to determine and this can be done after the chest wall has been partially resected and reflected.
      Figure thumbnail gr4
      Figure 4The thoracotomy shown has been performed in the fifth intercostal space. The chest wall resection is usually begun anteriorly. Occasionally, it is helpful to take a piece of the anterior ribs out to improve mobilization of the chest wall segment. The intercostal bundles are ligated individually. After the inferior and anterior sections have been mobilized, one can begin mobilizing the posterior segment of the chest wall resection.
      Figure thumbnail gr5
      Figure 5The posterior portion of the chest wall resection may be challenging if the tumor approaches the vertebral bodies. To improve exposure, I elevate the erector spinae muscles to identify the junction of the ribs with the transverse processes. If there is adequate distance between the rib and the transverse process, the head of the rib is disarticulated at the costovertebral joint using a periosteal elevator (A). If the costovertebral joint is involved, the transverse process should be transected flush with the lamina using a curved osteotome (B). The osteotome should be held at a right angle to the vertebral body to avoid entering the spinal canal. The intercostal bundles should be securely ligated with heavy silk ties or hemoclips to prevent bleeding and cerebrospinal fluid leaks. If more extensive vertebral body involvement is present, I have performed more extensive resections working with a neurosurgeon or an orthopedic spine surgeon.
      When possible, I prefer to perform the chest wall resection first followed by the pulmonary resection. The resected chest wall is left en bloc with the attached lung. The pulmonary resection is then performed in standard fashion. Occasionally, it is advantageous to perform the pulmonary resection first. If the lung is fixed posteriorly, an anterior, fissureless, approach is quite useful. In addition, the lobectomy may improve exposure to the medial, anterior chest wall and avoid tension on the pulmonary vessels.
      Figure thumbnail gr6
      Figure 6After the pulmonary and chest wall resection have been performed, a decision needs to be made about chest wall reconstruction. For defects greater than three ribs or 5 cm, some type of chest wall reconstruction is usually warranted. My first choice for lateral and posterior defects is 2-mm-thick Gore-Tex. This can also be quite useful when the fifth or sixth ribs have been resected posteriorly to prevent the scapula tip from caving into the chest. The Gore-Tex is measured after being placed over the chest wall defect. The patch is cut to size and sewn around the inferior and superior ribs with interrupted 0-0 Prolene suture. Anteriorly and posteriorly, it is helpful to drill a hole in the ribs. I have used the Midas Rex Gold Touch drill (Medtronic, Inc, Minneapolis, MN). The suture can then be passed through the holes and subsequently through the Gore-Tex. It is important to make sure that it is quite taut to prevent a flail segment. The chest tubes need to be inserted and the lung reinflated before finishing the chest wall reconstruction.
      Figure thumbnail gr7
      Figure 7Reconstruction with a Marlex/methyl methacrylate sandwich is very useful for large anterior defects. It provides excellent contour to the chest wall and better protection for underlying vital structures. Its major disadvantage is that it takes longer to prepare and construct. Two pieces of the Marlex mesh should be customized to the size of the chest wall defect. Moist lap pads are then placed into the chest to help contour the prosthesis. The sterile plastic package for the Marlex mesh is used to cover the lap pads and prevent the methyl methacrylate from sticking. The methyl methacrylate is then mixed and placed onto one piece of the mesh (A). It should be a thin coating and stay 1 cm from the edge. The second piece of Marlex is then placed on top to create the sandwich. This is then molded on top of the underlying lap pads to help create the contour of the chest wall. Appropriate curvature may be obtained by shaping the prosthesis while it undergoes its exothermic reaction (B). One needs to be careful as this reaction can reach temperatures of 104°F and the underlying lung and skin need to be protected.
      Once the prosthesis has hardened and cooled, it is lifted up and the underlying lap pads and plastic are removed. The Marlex rim is then sutured to the ribs as shown in (C). It is important not to oversize the methyl methacrylate portion as it can rub against the ribs and create postoperative pain. Some surgeons prefer to contour the prosthesis on the back table to avoid the potential risk of thermal injury. However, I have found it relatively easy to use this method and the contour of the prosthesis is excellent. The overlying serratus and latissimus muscles usually provide adequate soft-tissue coverage. In the rare event that these muscles required resection, a pedicled muscle flap should be performed for adequate soft-tissue coverage of the prosthesis.

      References

        • Burkhart H.M.
        • Allen M.S.
        • Nichols 3rd, F.C.
        • et al.
        Results of en bloc resection for bronchogenic carcinoma with chest wall invasion.
        J Thorac Cardiovasc Surg. 2002; 123: 670-675
        • Matsuoka H.
        • Nishio W.
        • Okada M.
        • et al.
        Resection of chest wall invasion in patients with non-small cell lung cancer.
        Eur J Cardiothorac Surg. 2004; 26 (See comment): 1200-1204
        • Doddoli C.
        • D’Journo B.
        • Le Pimpec-Barthes F.
        • et al.
        Lung cancer invading the chest wall: a plea for en-bloc resection but the need for new treatment strategies.
        Ann Thorac Surg. 2005; 80 (See comment): 2032-2040
        • Karmy-Jones R.
        • Vallieres E.
        Non-small cell lung cancer with chest wall involvement.
        Chest. 2003; 123: 1323-1325
        • McCormack P.M.
        Use of prosthetic materials in chest-wall reconstruction.
        Surg Clin North Am. 1989; 69: 965-976